Evidence-Based Practices in Drug and Alcohol Treatment and Recovery

Home , Alcohol (drug), Benzodiazepine overdose

Evidence-based Practices in Drug and Alcohol Treatment and Recovery

June 2016

Contents

Introduction 2

Principles and goals of substance abuse treatment 4

Evaluation and determination of therapeutic service need 5

Withdrawal management services—management of acute intoxication and withdrawal 8 Alcohol 8 Benzodiazepines 9 Opioids 9 Medication-assisted therapies 9 Stimulants (cocaine and amphetamine) 10 Cannabis withdrawal 10 Hallucinogens (LSD, mescaline, psilocybin, and related drugs) 10 Phencyclidine (PCP) 11 Volatile substances (inhalants) 11 Club drugs 11 Designer drugs 11 Anabolic-androgenic steroids (AAS) 12

Interventions—substance abuse treatment and recovery 13 Psychosocial treatments 13 Somatic treatments (Psychopharmacotherapy) 14 Medication-assisted treatment (MAT) 15

Levels of care 18

Conclusion 19

References 20

The use of illicit drugs, e.g., marijuana, cocaine, physiological symptoms indicating that the heroin, hallucinogens, inhalants, and nonmedical individual continues using the substance despite use of prescription-type psychotherapeutic drugs, substance-related problems” (DSM-5, 2013). SUDs and alcohol is both a significant public health occur when recurrent use of the substance results problem and a challenge in the U.S. A national in a pathological pattern of related behaviors, e.g., report, Behavioral Health Trends in the United impaired control and social impairment. The 2014 States: Results from the 2014 National Survey NSDUH reported that approximately 21.5 million on Drug Use and Health (NSDUH), reported the people aged 12 and older in 2014 had SUDs in most recent statistical information on the use of the past year, including 7.1 million with an illicit substances by the U.S. population aged 12 years or drug use disorder, 17 million with an alcohol use older (SAMHSA, 2015). According to the NSDUH disorder, and 2.6 million with both an alcohol use report, in 2014, the percentage of people aged 12 disorder and an illicit drug disorder. The NSDUH and older who used an illicit drug in the past 30 also reported that 4.2 million and 1.9 million people days was 10.2 percent, representing 27 million had past-year disorders related to marijuana use persons. Notably, this percentage was higher than and nonmedical use of prescription pain relievers, the percentages in every year from 2002 through respectively. Overall, the people who had SUDs in 2013. SAMHSA noted that this increase resulted 2014 represented 8.1 percent of the people aged 12 primarily from marijuana use and the nonmedical or older, similar to the percentages in 2011 – 2013 use of prescription pain relievers. In 2014, the and lower than the percentages in 2002 to 2010 percentage of people aged 12 or older who were (SAMHSA, 2015). current marijuana users (8.4 percent) was greater than the percentages in 2002 to 2013, while the Published data from the National Institute on Drug percentage of people who were current nonmedical Abuse (NIDA) reported that prescription drug users of pain relievers (1.6 percent) was lower abuse is a significant problem in the U.S. (NIDA, than the percentages in most years from 2002 to 2015). The abuse and diversion of prescription 2012, although similar to the percentage in 2013. drugs is highest among young adults (age 18 to However, the percentage of people aged 12 or older 25) who use the drugs for various reasons, e.g., to in 2014 who were current heroin users was higher produce euphoria, or they may believe stimulants than percentages in most years from 2002 – 2013 will improve academic performance. In 2014, (SAMHSA, 2015). the percentages of various age groups using prescription drugs for nonmedical reasons in the The NSDUH reported that, in 2014, 66.9 million past year were as follows: 6 percent of 12-17 year- individuals (25.2 percent) aged 12 and older were olds; 12 percent of 18-25 year-olds; and 5 percent current users of tobacco products, and 139.7 million of persons 26 years or older (NIDA, 2015). The individuals (52.7 percent) were past month alcohol Centers for Disease Control and Prevention (CDC) drinkers. Tobacco and cigarette use were lower indicated that the U.S. is experiencing an epidemic across all age groups in 2014 than in most years of drug overdose deaths, with more persons (47,055) from 2002 to 2013. Although in 2014 the percentage dying from drug overdoses in the U.S. in 2014 than of people aged 12 or older who were past-month during any previous year on record (CDC, 2015). alcohol users was approximately the same as in The main drugs associated with overdose deaths years 2009-2013, the report stated that binge alcohol are prescription pain relievers and heroin. The rate use and heavy alcohol use among young adults, of opioid overdoses tripled from 2000 to 2014 and aged 18 to 25, was high at 37.7 percent and 10.8 in 2014, opioids were involved in 61 percent of all percent respectively (SAMHSA, 2015). drug overdose deaths. Trends noted by the CDC are a 15-year increase in overdose deaths involving Substance use disorders (SUDs) are characterized prescription opioid pain relievers and the recent by “a cluster of cognitive, behavioral, and surge in illicit opioid overdose deaths, driven by

2 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc heroin primarily. The CDC discussed the need to To underscore the magnitude and complexity improve safer prescribing of prescription opioids of the problem related to substance use, it is (prescribing has quadrupled since 1999 increasing important to note that in 2014, 39.1 percent of the in parallel with overdoses) and emphasized the adults aged 18 or older with a past-year SUD also need to expand access to medication-assisted had a diagnosed co-occurring mental disorder treatment, in combination with behavioral therapies (SAMHSA, 2015). Among adults without a past year (CDC, 2015). A report by the National Council on SUD, only 16.2 percent had any diagnosed mental Alcohol and Drug Dependence (NCADD) reported disorder. The percentage of adults with SUD and that more than 47,000 Americans died of a drug co-occurring mental disorder in 2014 was similar overdose in 2014, an increase of 7 percent from the to the percentages in most years from 2008 to previous year. NCADD reported that the increase 2013. In 2014, 11.3 percent of the adults aged 18 or from 2013 to 2014 was driven largely by deaths older with a past-year SUD also had a diagnosed from heroin and prescription opioids. Overdose serious mental illness (SMI), which was similar to deaths due to opioid painkillers (almost 19,000) the percentages of adults with SMI in most years and heroin increased by 16 percent and 28 percent, from 2008 to 2013. Additionally, among the adults respectively. NCADD further reported that the rise with SMI in 2014, 23 percent also met the criteria in opioid-related deaths is due in part to synthetic for an SUD in the past year. Moreover, “people with opioids, such as fentanyl (increasing the effect of a mental disorder are more likely to experience a heroin) (NCADD, 2016). substance use disorder and people with a substance use disorder are more likely to have a mental On March 22, 2016, the U.S. Food and Drug disorder when compared to the general population” Administration (FDA) announced a new black (SAMHSA, 2015). The National Survey of Substance box warning for immediate-release (IR) opioid Abuse Treatment Services (N-SSATS) reported that pain medication related to risk of misuse, abuse, approximately 45 percent of persons in the U.S. addiction, overdose and death (FDA, 2016). seeking treatment for SUD have been diagnosed as Additionally, the warning on IR opioid analgesics having a co-occurring mental and substance use includes a precaution about their use during disorder. This represents one of the most significant pregnancy. As a part of the agency’s overall efforts problems facing the public mental health system to help reverse the prescription drug epidemic today. In addition, the abuse of multiple substances and to inform prescribers about the importance is common and can complicate the assessment/ of balancing the serious risks of opioids with treatment of withdrawal syndromes, management their role in managing pain or when used for of associated medical conditions, and rehabilitation medication-assisted treatment, several additional efforts aimed at relapse prevention and recovery safety labeling changes across all prescription (SAMHSA, 2015). opioid products (both extended release [ER] and IR products) are now required. Substance abuse treatment providers utilize comprehensive/high-quality screening tools, A recent study described trends in benzodiazepine clinical practice guidelines, treatment protocols prescriptions and related overdose mortality and placement criteria developed and published (Bachhuber et al., 2016). Authors reported that by professional associations/government agencies, the number of adults filling a benzodiazepine e.g., American Psychiatric Association (APA), prescription increased 67 percent between American Society of Addiction Medicine (ASAM), 1996 and 2013; the percentage of adults filling U.S. Department of Health and Human Services, a benzodiazepine prescription increased 4.1 Substance Abuse and Mental Health Services percent to 5.6 percent; and the total quantity filled Administration (SAMHSA), National Institute on more than tripled. However, the rate of overdose Drug Abuse (NIDA) and others. These represent mortality involving benzodiazepines rose at a analyses, summaries and consensus reviews of faster rate than the percentage of individuals evidence-based practices for all phases of alcohol/ filling prescriptions as well as the quantity filled drug treatment and recovery. (Bachhuber et al., 2016).

Substance abuse treatment is conceptually divided and prior nonmedical use of pain relievers. It also into phases and defined by SAMHSA in their includes information about the use of marijuana, Treatment Improvement Protocol (TIP) 42— now legal in many states for medical or recreational Substance Abuse Treatment for Persons With Co- use. The Diagnostic and Statistical Manual of Occurring Disorders and TIP 45—Detoxification Mental Disorders Fifth Edition DSM-5 (2013) and Substance Abuse Treatment as engagement, added craving as a new criterion within substance stabilization, primary treatment and continuing use disorders. Magellan’s updated guideline cites care (or aftercare). In these phases, the clinician studies suggesting that cravings may be reduced should apply approaches to treatment that promote and relapse prevented by the use of medications a recovery-focused orientation (SAMHSA, 2006; combined with behavioral therapies to treat SUD. SAMHSA, 2005). Medication-assisted treatment (MAT) also has been associated with fewer inpatient admissions in The APA Practice Guideline for the Treatment of individuals with alcohol dependence. The updated Patients With Substance Use Disorders, Second guideline cites studies reflecting that few clinicians Edition (2006) specifies that since SUDs are prescribe medications to treat alcohol dependence considered “heterogenous with regard to a number while treating mood disorders. Research of clinically important features and domains of suggests that clinicians consider a program functioning…a multimodal approach to treatment integrating evidence-based psychosocial and is typically required” and tailored to specific psychopharmacological interventions for treatment individualized needs of the patient. (APA, 2006, p. of young adults with co-occurring substance use 9) Treatment of individuals with SUDs includes and psychiatric disorders. Other studies cited conducting a complete assessment, treating in the guideline discuss SUDs as a key driver of intoxication and withdrawal syndromes when the overdose epidemic and note three types of necessary, addressing co-occurring psychiatric MAT, often underutilized, used in the treatment and general medical conditions, and developing of patients with opioid addiction: methadone, and implementing a plan. The APA indicates that buprenorphine, and naltrexone. The guideline goals of treatment include motivating the patient includes a quote from the American Society of to change their attitudes and behaviors to be more Addiction Medicine’s (ASAM) The ASAM Criteria, conducive to recovery and relapse prevention. The “every day, in fact every 19 minutes, an American use of engagement therapies such as motivational dies from an unintentional drug overdose. This enhancement therapy can help patients work epidemic is compounded by the vast gap in access through their ambivalence about recovery. to opioid addiction treatment. This does not have to Additionally, the purpose of treatment should help be our patients’ realities” (ASAM, 2013). the patient reduce use of the substance or achieve complete abstinence, reduce the frequency and severity of substance use episodes, and improve psychological and social functioning (APA, 2006; APA, 2007).

The Introduction to Magellan’s Adopted Clinical Practice Guidelines for the Assessment and Treatment of Patients With Substance Use Disorders (March 2015) provides additional as well as more up-to-date information based on current research. Magellan’s update discusses the association between the increase in number of persons in the U.S. using heroin for the first time

A very broad and flexible continuum of substance as a “primary, chronic disease of brain reward, abuse care accommodating individualized motivation, memory, and related circuitry… and assessment-driven treatment is in place in characterized by inability to consistently abstain, many areas of the U.S. The American Society of impairment in behavioral control, craving, Addiction Medicine’s (ASAM) comprehensive set of diminished recognition of significant problems with guidelines describing the continuum of addiction one’s behaviors and interpersonal relationships, and health services, The ASAM Criteria: Treatment a dysfunctional emotional response” (Mee-Lee et Criteria for Addictive, Substance-Related, and al., 2013, p. 10). Co-Occurring Conditions, Third Edition (ASAM Criteria), discusses the clinical components ASAM’s six dimensions of multidimensional and programmatic construct of the treatment assessment are acute intoxication and/or continuum in depth. Use of this clinical guide may withdrawal potential; biomedical conditions improve assessment and outcomes-driven treatment and complications; emotional, behavioral, and recovery services for patients matched to or cognitive conditions and complications; appropriate treatment settings, interventions and readiness to change; relapse, continued use, levels of care. The goal of addiction treatment or continued problem potential; and recovery/ services is not simply stabilizing the patient’s living environment. These dimensions include condition, but altering the course of the patient’s exploration of the following: individual’s past disease toward wellness and recovery and and current experiences of substance use and productive functioning in family, workplace, and withdrawal; health history and current physical society. The ASAM Criteria does not use the term examination; thoughts, emotions and mental “detoxification services” and refers instead to health issues; readiness and interest in changing; “withdrawal management” (Mee-Lee et al., 2013). relationship with relapse or continued use; and individual’s recovery or living situation (Mee-Lee et The guiding principles of the ASAM criteria for al., 2013). addictive, substance-related, and co-occurring conditions include multidimensional assessment; A multidimensional assessment identifying needs, individualized, person-centered treatment; strengths, skills and resources leads to dimension- individualized length of stay; broad and flexible specific risk ratings, followed by service planning continuum of care where patients may move to a and placement. “The ASAM Criteria describes more or less intensive level based on individual treatment as a continuum marked by broad levels needs; identification of adolescent-specific needs; of service and an early intervention level” (Mee-Lee comprehensive biopsychosocial assessment et al., p.106), Levels of care represent intensities of patient and family; removal of previous of service along a continuum of recovery-oriented “treatment failure” as a requirement for placement; addiction services rather than a limited number of interdisciplinary, team approach to care; team traditional program facilities and settings. The six approach including not only physicians but also dimensions of multidimensional assessment can addiction specialists, physician assistants, nurse be applied to each level of care. Levels of care are practitioners, peer support specialists/recovery determined by an individual person’s needs, and the coaches, and other healthcare professionals; focus length of stay in that level depends on the severity on patient engagement and treatment outcomes; of illness, level of function, and progress made in informing patient and family members of modalities treatment. of treatment, alternative treatments, and risks of treatment versus no treatment; clarification of “medical necessity” defined by problems in all multidimensional assessment areas; and incorporation of ASAM definition of addiction

1. Level 0.5 Early Intervention

2. OTP-Level 1 Opioid Treatment Program

3. Level 1 Outpatient Services

4. Level 2.1 Intensive Outpatient Services

5. Level 2.5 Partial Hospitalization Services

6. Level 3.1 Clinically Managed Low-Intensity Residential Services

7. Level 3.3 Clinically Managed Population-Specific High-Intensity Residential Services

8. Level 3.5 Clinically Managed High-Intensity Residential Services

9. Level 3.7 Medically Monitored Intensive Outpatient Services

10. Level 4 Medically Managed Intensive Inpatient Services

In the U.S., 8.9 million adults have co-occurring present” (Priester et al., p. 57). Authors concluded, mental health and substance use disorder (COD) “Integrated services must be flexible and client- (SAMHSA, 2015). Patients with COD have at least centered to maximize treatment accessibility for one mental illness and one SUD, each of which individuals with COD, particularly those who face must be able to be diagnosed independently structural barriers to treatment” ( Priester et al., (Priester et al., 2016). SAMHSA reported that 2016). The ASAM Criteria incorporates updated only 7.4 percent of individuals with COD receive terminology regarding co-occurring conditions treatment for both disorders and 55 percent receive and co-occurring capability, eliminating specific no treatment at all. In an integrative literature definition for addiction-only services.Co-occurring review, authors examined barriers to treatment capability represents a shifting focus toward access for individuals with COD (Priester et al., holistic, person-centered services delivered in 2016). Structural barriers to treatment included an integrated fashion for individuals with co- service availability, disorder identification, provider occurring conditions (Mee-Lee et al., 2013). training, service provision, racial/ethnic disparities, and insurance/policy related barriers. Service The APA guideline stresses the importance of availability is a primary structural barrier involving careful diagnostic distinction between symptoms lack of specialized services, e.g., residential or of substance abuse and symptoms of other co- rehabilitation programs, intensive inpatient care, occurring psychiatric disorders, as this dictates etc. Under-identification rates also are barriers; the selection of appropriate and targeted often either a SUD or a mental health disorder is pharmacotherapy and psychosocial interventions. identified, but not both. Personal characteristics, The guideline recommends appropriate treatment e.g., personal vulnerabilities and personal of a specific psychiatric disorder in most cases beliefs are barriers to treatment as well. Authors whether or not that disorder co-exists with a SUD. suggested, “flexible, community-based, wrap- However, the guideline indicates that clinicians around services that address substance use, mental must pay special attention to each medication’s health, and basic needs in an integrated way may tolerability and safety profile as well as its abuse increase the likelihood of individuals accessing potential (APA, 2006), for example medications treatment when significant barriers such as that are likely to create dependence such as transportation, childcare, and geographic proximity benzodiazepines should not be used to treat to services in resource-poor, rural communities are anxiety.

6 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc SAMHSA TIP 42 also offers the following guidance for working with clients with COD: (1) employ a recovery perspective (2) adopt a multi-problem viewpoint (3) address specific personal and social problems early in treatment (4) plan for the client’s cognitive and functional impairments and (5) use support systems (SAMHSA, 2005).

Withdrawal management, formerly called Withdrawal Scale [COWS]). The instruments can detoxification services, includes interrupting the accurately measure withdrawal syndromes and momentum of habitual compulsive use as well as guide selection of pharmacological agents. This attenuation of the physiological and psychological has lead to a greater understanding of which features of withdrawal (ASAM, 2013). Services withdrawal symptoms need supportive vs. medical include breaking the cycle of use, enabling the management (Magellan, 2015). patient to establish abstinence, and evaluation of the need for further care. A greater intensity of Several drugs/classes currently associated services is required to establish initial treatment with withdrawal phenomenon include alcohol, engagement and patient involvement. ASAM amphetamines, caffeine, cannabis, stimulants points to how current medication protocols allow (i.e., cocaine and amphetamines), nicotine, management on an ambulatory basis, except opioids, sedative-hypnotics (i.e., benzodiazepines for the most severe withdrawal syndromes. It is and barbiturates), anabolic-androgenic steroids critical to continue withdrawal support at less (AAS), and club drugs (MDMA [3, 4-methy- intensive levels of withdrawal management. ASAM lenedioxymethamphetamine], GHB [gamma- states, “a ‘successful detox’ encounter involves hydroxybutyrate], Rohypnol [flunitrazepam], more than acute management of withdrawal. It and ketamine). Recent designer drugs or involves engagement in services to address the “legal highs,” also associated with withdrawal accompanying addiction process and thus reduce phenomenon and prevalent among young adults, the likelihood of ‘readmission for detox’” (Mee-Lee include substituted or synthetic cathinones et al., 2013). (bath salts), e.g., mephedrone, methylone, and methylenedioxypyrovalerone (MDPV); and According to SAMHSA TIP 42, “outpatient synthetic cannabinoids, e.g., Spice. Only alcohol detoxification is becoming the standard to and the sedative-hypnotics are associated with treatment of symptoms of withdrawal from potentially life-threatening withdrawal syndromes. substance dependence” and “more than 90 percent Drugs/classes that are not associated with of alcohol treatment programs could safely manage withdrawal include inhalants, hallucinogens, and patients with withdrawal syndromes as outpatients phencyclidine (PCP). Following is a synopsis of after careful screening for those who may need evidence-based interventions for the monitoring inpatient treatment” (SAMHSA, p.20) The SAMHSA and management of potential withdrawal states protocol stresses that careful screening is essential (Magellan, 2015; Magellan, 2007). to reserve inpatient treatment for those clients: • With possible complicated withdrawal states Alcohol • With co-morbid medical conditions— Quantitative measures of withdrawal in rating e.g., diabetes, hypertension, pregnancy scales, e.g., CIWA-Ar, may guide treatment • With suicidal/homicidal/psychotic states interventions. Approximately 95 percent of individuals experience only mild to moderate • In danger of seizure or delirium tremens (DTs) withdrawal. However, patients with a past history • With no capacity for informed consent. of withdrawal symptoms may be in the process of going into withdrawal while their symptoms are Most admission criteria today have been still minimal. Therefore, prior to the intensification considerably refined using scientifically validated of symptoms, initiating medications may prevent assessment tools and rating scales (e.g., severe withdrawal. Individuals with CIWA-Ar Clinical Institute Withdrawal Assessment for scores below 10 may not need pharmacologic Alcohol, revised [CIWA-Ar] and Clinical Opiate

8 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc interventions and may be managed on an outpatient dicyclomine, trazodone and/or hydroxyzine. basis. CIWA-Ar scores between 10 and 20 usually Methadone or buprenorphine also may be used require pharmacologic intervention and medical/ for detoxificaton, but only with appropriate nursing supervision, which may or may not certification. be managed on a less than 24-hour/day basis. CIWA-Ar scores of 20 or higher are candidates Medication-assisted therapies for consideration for a hospital level of medical withdrawal management. Benzodiazepines are • Medication-assisted therapies used in treating the most commonly used agents to treat alcohol patients with opioid addiction include withdrawal (i.e., diazepam, chlordiazepoxide and methadone, buprenorphine, and naltrexone. If lorazepam) using a fixed schedule/tapering dosage not successful in reaching goals of withdrawal method or a symptom-targeted method. For patients management or if experiencing intolerable side with liver impairment, lorazepam or oxazepam effects, patients may switch from methadone should be used due to lower potential for hepatic to buprenorphine, oral naltrexone, or toxicity. The use of phenobarbital is rarely used extended-release injectable naltrexone. Prior except in certain cases where resistant patients do to a switch to buprenorphine, patients should not respond to large doses of benzodiazepines. For be on low doses of methadone (30-40 mg per mild to moderate withdrawal symptoms (CIWA<15), day or less). When switching from methadone anticonvulsants (i.e., carbamazepine, gabapentin to oral naltrexone or extended-release and valproic acid) can be used as alternative to injectable naltrexone, patients generally must benzodiazepines. While alpha-adrenergic agonists, be completely withdrawn from methadone and beta-blockers and calcium channel blockers may other opioids (ASAM, 2015). Recent studies control symptoms of acute alcohol withdrawal, have found that buprenorphine-naloxone there is insufficient efficacy for their use in the compared to methadone, has a lower abuse prevention of seizures or DTs. potential, allows for more flexibility, and carries less stigma (Mauger et al., 2014). Whereas methadone is administered Benzodiazepines under the opioid treatment program (OTP) Individuals who are dependent on low doses of on a daily basis without the prescribing of benzodiazepines may receive a quick tapering with medications, buprenorphine can be prescribed or minimal discomfort, but the usual tapering process administered by physicians (who have received requires from one to four weeks. Individuals waiver to prescribe buprenorphine) in private dependent on high doses of benzodiazepines practices or other types of public sector clinics may be withdrawn using one of the following under the office-based opioid treatment (OBOT). methods: substituting a long-acting benzodiazepine Studies have shown that in a primary care tapered over two to six weeks as the preferred office, buprenorphine treatment combined with method; tapering the dosage of the original counseling may be most effective in treating agent of dependence; or converting the dosage of patients with opioid dependence (Neumann et benzodiazepine to be withdrawn to a phenobarbital al., 2013). It has no depression of respiration and equivalent. After stabilization, the individual thus is much safer than methadone. A recent receives an individualized tapering-off regimen. study showed buprenorphine maintenance treatment to be as effective as methadone Opioids maintenance treatment in reducing illicit opioid use and was associated with less risk of adverse ASAM cautions that abrupt cessation of opioids events. Results of the study suggested that due may lead to strong cravings and continued use, to limited access to methadone maintenance and recommends the use of medications for opioid treatment as well as its more restrictive withdrawal management (ASAM, 2015). Medications safety profile,buprenorphine maintenance for the management of withdrawal symptoms treatment should be considered for the can include clonidine, ibuprofen, methocarbamol,

©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 9 long-term management of opioid use associated with antagonist treatment and disorders. Improved access to care as well as thus no possibility of precipitated withdrawal” earlier initiation of treatment improves access (ASAM, 2015, p. 20). to care as well as earlier initiation of treatment (Thomas et al., 2014). Monitoring of medication Stimulants (cocaine and amphetamine) administration until the patient’s clinical response and behavior demonstrate appropriate Stimulant withdrawal does not directly cause prescribing is required. life-threatening withdrawal symptoms, seizures or delirium and no medications have been developed • The initial dose of buprenorphine should be 2 specifically for this purpose, and treatment is mg to 4 mg and increased in increments of 2 mg usually observation. Individuals who have abused to 4 mg. Initial use of this medication usually large amounts of stimulants may experience a produces a mild withdrawal syndrome which can withdrawal syndrome and intense depression, usually be managed on an outpatient, intensive which requires monitoring for suicide potential. Due outpatient or partial hospital basis. Although to persistent cardiac complications associated with clinicians should observe patients in their offices cocaine abuse, evaluation of chest pain is necessary or in one of the aforementioned higher clinical along with evaluation of persistent headaches to settings during induction, home-based induction rule out subdural, subarachnoid or intracerebral of buprenorphine is reasonably safe for selected bleeding. patients. After induction and titration, doses should be at least 8 mg per day except when patients continue to use opioids, daily dose of Cannabis withdrawal buprenorphine may be increased to 12 to 16 mg Cannabis withdrawal is covered as a new or higher (FDA approves a limit of 24 mg per disorder in DSM-5. The ingredient THC (delta-9- day). No time limit for treatment has been set. tetrahydro-cannabinol) component of marijuana Buprenorphine tapering is a slow process and and hashish may be associated with withdrawal generally takes several months. If switching from (i.e., THC abstinence syndrome) after cessation of buprenorphine to naltrexone, there should be prolonged cannabis usage. Signs or symptoms of a lapse of 1 to 14 days between the last dose of cannabis withdrawal cause distress or impairment buprenorphine and the start of naltrexone. in important areas of functioning and are not • Oral naltrexone is considered for patients based attributable to another medical condition. There on personal preference or where adherence are currently no evidence-based pharmacotherapy can be enforced or supervised, while extended- treatments for cannabis withdrawal (DSM-5, 2013). release injectable naltrexone is considered for patients having issues with adherence. Daily Hallucinogens (LSD [d-lysergic acid dosage for oral naltrexone is 50 mg or it can be diethylamide], mescaline, psilocybin, and given three times weekly (two 100 mg doses and related drugs) one 150 mg dose). Extended-release injectable Withdrawal syndromes have not been reported naltrexone is administered every four weeks at and medical detoxification is not necessary. a dosage of 380 mg per injection (ASAM, 2015). However, there are residual effects such as delayed Naltrexone can be used only when the patient is perceptual illusions with anxiety (“flashbacks”), completely detoxified from opiates. psychotic symptoms and long-term cognitive • It is important to remember, “switching from an impairment, which often require psychiatric antagonist such as naltrexone to a full agonist attention. Synthetic hallucinogens, e.g., 25I-NBOMe, (methadone) or a partial agonist (buprenorphine) have been increasingly popular since 2011 often is generally less complicated than switching resulting in negative psychiatric consequences, e.g., from a full or partial agonist to an antagonist delirium, agitation, paranoia, confusion, and self- because there is no physical dependence harm.

10 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc Phencyclidine (PCP) of intensive medically managed benzodiazepine withdrawal apply in these cases (as previously Withdrawal from PCP is very rare and no described). Chronic users of ketamine, a derivative detoxification is necessary other than controlling of PCP, become addicted and exhibit severe the symptoms of intoxication. Since patients with withdrawal symptoms along with bizarre ideations acute PCP intoxication often become violent and hallucinations that require detoxification with and experience a drug-induced psychosis (i.e., benzodiazepines. hallucination, delusions) with manic behavior, hospitalization is necessary to monitor the patient in a safe environment and treat symptoms with Designer drugs psychotherapeutic agents (i.e., benzodiazepines One of these substances, also known as “legal and/or antipsychotic agents). highs,” includes substituted or synthetic cathinones (bath salts). Relatively new designer drugs, Volatile substances (inhalants) bath salts (Ivory Wave, Vanilla Sky, meow-meow, M-Cat) are especially popular among young adults. Inhalants are a large and varied group of Primary substituted cathinones are part of the psychoactive substances found in household, family of stimulants and include mephedrone, industrial and medical products (i.e., adhesives, methylenedioxpyrovalerone (MDPV), and aerosols, anesthetics and cleaning agents) that are methylone (Molly). Common effects of bath salts inhaled for the short-lived “high” or “head rush” include talkativeness, euphoria, and increased and loss of inhibitions. Inhalants do not cause any energy. With larger consumption and/or where serious degree of physical dependence and since consumed with other substances, acute agitation withdrawal symptoms are uncommon, there is no may occur resulting in paranoia, hallucinations, specific detoxification protocol. and delusions. Tolerance occurs after repeated dosing including large amounts of the substituted Club drugs cathinones, with some users experiencing a These substances are known by this moniker diagnosable SUD. Withdrawal effects including because they are used at dance parties, raves and tiredness, irritability, depression, and insomnia nightclubs in order to intensify social experiences have been reported among chronic users. With a by giving a reported sense of physical closeness, lack of specific antidotes, supportive treatment empathy and euphoria. The most prominent “club including a quiet environment may treat unpleasant drugs” are MDMA or “ecstasy” (3, 4-methy- psychological effects of acute intoxication, e.g., lenedioxymethamphetamine), GHB (gamma- agitation. Once a drug use disorder is diagnosed, hydroxybutyrate); Rohypnol or “date rape” drug treatment may include behavioral components, (flunitrazepam) and Ketalar (ketamine). The e.g., cognitive behavioral therapy and motivational focus of treatment for MDMA is to manage the enhancement. Treatment may be difficult due to complications of intoxication and overdose (i.e., concurrent polysubstance use and the young age of sympathetic overload, “serotonin syndrome,” most users (Weaver et al., 2015). Another designer end-organ damage, respiratory distress and drug is synthetic cannabinoids (Spice, K2, K9, coagulopathy) but not withdrawal, since it is Aroma, herbal highs), which has effects similar to not addictive. Chronic use of GHB may produce cannabis. Acute psychosis may result from its use. dependence and a withdrawal syndrome that A dependence syndrome and withdrawal symptoms includes anxiety, insomnia, tremor, delirium, and in are similar to those seen with cannabis. Synthetic severe cases, treatment-resistant psychoses. Mild hallucinogens are other popular designer drugs. cases of GHB may be managed with benzodiazepines The use of 25I-NBOMe (N-bomb, Solaris, Smiles, and supportive care and more severe withdrawal Cimbi-5), popular in recent years, may result in requires high doses of intravenous benzodiazepines visual and auditory hallucinogens, similar to the or barbiturates. Since Rohypnol is a benzodiazepine effects of psilocybin. Although psychosis due to with 10 times the potency of diazepam, the principles synthetic cannabinoids and synthetic hallucinogens

©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 11 may be managed with monitored observation, benzodiazepines may be used to treat symptoms such as anxiety and agitation (Weaver et al., 2015).

Anabolic-androgenic steroids (AAS) While the addiction to steroids (“performance enhancing drugs”) has generally been described as a psychological addiction, there are withdrawal effects which occur after stopping—i.e., depression, fatigue, paranoia, suicidal thoughts/feelings and strong desire to continue using the steroids. A tapering-off protocol for high doses of steroid uses substitution testosterone enanthate in gradually decreasing doses. Clonidine may be useful in managing an opiate-like withdrawal mechanism, and a short course antipsychotic medication and benzodiazepines may control symptoms of panic or anxiety.

Psychosocial treatments conditioned craving. Twelve-step facilitation Psychosocial treatment is an essential component is a structured technique (usually manual- of a comprehensive treatment program as it driven) that enhances patient motivation to work can assist patients in coping with the emotional through a 12-step program. Psychodynamic and and social challenges that often accompany interpersonal therapies are classic modalities substance use disorders (ASAM, p. 100). Cognitive, that focus on traumas/deficits during an individual’s behavioral and motivation treatments are well- development or dysfunctional social relationships defined and have been rigorously studied across that contributed to the addiction disorder. They a broad range of SUDs—i.e., alcohol, stimulant, have been used successfully in facilitating marijuana and opioid dependent populations. abstinence, especially when combined with other Psychosocial treatment is widely available in the treatment modalities (e.g., self-help groups and clinical community and in a variety of convenient pharmacotherapy). Group therapy of many types formats (e.g., books, videotapes, manuals, training (e.g., CBT, interpersonal, behavioral marital, resources and computer-based/Internet delivered). modified psychodynamic interactive, rational The APA guideline indicates that while these emotive, Gestalt and psychodrama) may be used as modalities employ a variety of techniques and a supportive, therapeutic or educational tool and theories, they all focus on achieving the following provides opportunities for the group to respond to critical tasks (APA, 2006): early warning signs of relapse. Family therapy can help families adjust when a patient’s abstinence • Enhancing motivation to stop or reduce upsets a previously well-established style of family substance use interaction. Family peers or mentors can provide • Teaching coping skills support and information, helping families build the • Changing reinforcement contingencies necessary skills required to support treatment and recovery. Peer support, self-help and 12-step- • Fostering management of painful affects oriented programs are broadly available whereby • Enhancing social supports and interpersonal patients can engage and participate at any stage functioning. of their illness/recovery, even if still actively using substances. These mutual self-help programs Cognitive behavioral therapies (CBTs) include endorse the need for abstinence and use the power specific types such as standard cognitive therapy, of group support and identification in order to social skills training, and relapse prevention. provide strength and hope to one another. They These treatments all share the goal of altering are seen as an important adjunct to any substance dysfunctional cognitive processes that lead to abuse treatment program (APA 2006; Carroll et al., maladaptive behaviors. 2007). Motivational enhancement therapy motivates More formal peer support services are recognized the patient by exploring pros and cons of specific as an evidence-based practice, firmly grounded behaviors in order to create specific goals and in research and practice. These peer supporters understanding ambivalence. Behavioral therapies may have different titles (e.g., recovery coach, peer employ specific techniques such as contingency recovery specialists, etc.), but the philosophical management rewarding abstinence; community foundation and practical aspects of these supports reinforcement providing natural alternative are consistent. They provide social support for reinforcers to abstinence; and cue exposure and recovery, build on strengths and resilience, and relaxation techniques facilitating extinction of promote self-direction, empowerment, and choice

©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 13 (CSAT, 2009). Peer supporters also excel at quickly potent agonist at mu opiate receptor site); building therapeutic connections with individuals, buprenorphine (a potent long-acting compound particularly those with dual disorders, who are acting as a partial opioid agonist at mu typically considered to be the most alienated from receptor sites) and buprenorphine/naloxone healthcare systems (Sells et al., 2006). In addition, combination tablet. These medications also peer support (formal and informal) help individuals prevent euphoria if the patient relapses on living with drug and alcohol abuse develop or opioids. rebuild Recovery Capital. Recovery Capital is • Antagonist therapies—drugs that block or defined as the quantity and quality of internal and counteract the physiological and/or subjective external resources that one can bring to bear on the reinforcing effects of substances, i.e., naltrexone initiation and maintenance of recovery from a life- (blocks the subjective and physiological effects changing disorder (Granfield et al., 1999). This helps of opioid drugs without tolerance developing to provide a sense of belonging within a community this antagonist effect) in oral and sustained- of peers and supportive relationships with caring release long-acting injectable forms for use others. Peer support is an essential element of in both alcohol dependence and opioid relapse successful, recovery-oriented treatment and long- prevention following detoxification. term recovery. • Abstinence-promoting and relapse prevention therapies—drugs that allow Somatic treatments brain cells to readapt to a normal drug-free (psychopharmacotherapy) state, i.e., acamprosate (a small molecule that The APA guideline supports medication therapies for resembles GABA and decreases glutamatergic SUDs as effective adjuncts to behavioral therapies neurotransmission) may relieve symptoms of and self-help groups, which may be employed in protracted withdrawal and reduce neuronal the entire range of treatment levels and settings. hyperexcitability during early recovery; the The guideline specifies the appropriateness and sustained-release antidepressant, bupropion, effectiveness of medications to treat SUDs as has antagonism of high-affinity nicotinic categorized below (APA, 2006; APA, 2007): acetylcholine receptors; disulfiram (Antabuse) • Medications to treat intoxication states— is an inhibitor of the enzyme aldehyde naloxone (a competitive antagonist for all three dehydrogenase and when taken provides an types of opiate receptors—mu, kappa and aversive reaction to the consumption of alcohol sigma) for acute opioid overdose; flumazenil (a by causing nausea, vomiting, headache and potent benzodiazepine-specific antagonist that flushing through the accumulation of toxic competes at central synaptic GABA receptor levels of acetaldehyde; naltrexone, an opioid sites) for acute benzodiazepine overdose. receptor antagonist, works through blockage of mu opioid receptors reducing the reinforcing • Medications to treat withdrawal effects of alcohol and leads to decreased symptoms—drugs that provide cross feelings of intoxication and cravings; by tolerance in the same pharmaceutical class, blocking GABA receptors the anticonvulsant, i.e., methadone or buprenorphine for opioid topiramate, though not approved by the FDA for withdrawal; benzodiazepines for alcohol this indication, helps patients reduce drinking and sedative hypnotic withdrawal; nicotine or avoid relapse to heavy drinking; and the replacement therapies (NRT) for nicotine antispasmodic muscle relaxant, baclofen, dependence—gum, lozenges, nasal spray, mediates alcohol intake and its motivational inhalers. properties, and reduces anxiety in patients with • Agonist maintenance therapies—drugs alcohol dependence and liver impairments as it is that are used to relieve cravings associated excreted in the kidney. abstinences and unpleasant withdrawal symptoms, i.e., methadone (a long-acting

14 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc • Medications to treat co-occurring supports integrating behavioral interventions and psychiatric conditions—combination counseling with an appropriate medication as naltrexone and the selective serotonin reuptake this “can have a synergistic or additive effect and inhibitor (SSRI) antidepressant, sertraline, improve outcome” (p. 6). The TIP 49 further notes, while receiving weekly cognitive behavioral “Medication can reduce the cravings that disrupt therapy result in higher alcohol abstinence rates recovery. When cravings are decreased, counseling and longer delay before relapse to heavy drinking is more likely to strengthen the individual’s in addition to reducing depression in patients coping resources, which are necessary to promote with alcohol dependence and co-occurring medication adherence and behavioral change.” depression. Further, MAT of alcohol use disorder and opioid dependence are administered in physician office- Medication-assisted treatment (MAT) based settings making treatment more available and improving continuity and accessibility of care. In 2014, approximately 21.5 million Americans ages MAT of these disorders is “reasonable, practical and 12 and older (8.1 percent) had a SUD in the past a desirable trend that should be greatly expanded” year. Out of these, 2.6 million had both alcohol and (SAMHSA, p.6). drug problems, 4.5 million had drug problems only, and 14.4 million had alcohol problems only. The A recent systematic review, summarizing 55 use of FDA-approved medications in combination articles, focused on comparisons of medications with evidence-based behavioral therapies, referred and behavioral therapies to identify factors to as “medication-assisted treatment,” provides a associated with higher rates of retention in MAT for “whole-patient” approach to treating SUDs that has opiate dependence; i.e., treatment with methadone, been found effective in treating addiction to alcohol buprenorphine, and naltrexone (Timko, 2016). and opioids. Opioid use disorders are treated by Authors noted that retention in treatment is a three FDA-approved medications, i.e., methadone, primary outcome in treating opiate dependence buprenorphine, and naltrexone. Additionally, because retention is associated with patients’ naloxone treatment may prevent opioid overdose achieving outcomes, e.g., decreased drug use, deaths. The FDA approved three medications for improved social functioning and quality of life, alcohol use disorders: acamprosate, disulfiram, and and reduced mortality. This review found patients naltrexone. The use of medications in the treatment receiving naltrexone or buprenorphine had better of alcohol and drug problems, when combined with retention rates (3-, 6-, or 12-months) than patients behavioral therapies, i.e., individual therapy, group receiving no medication or a placebo. An advantage counseling, and family behavior therapy; cognitive- was found for methadone over buprenorphine as behavioral therapy, and motivational enhancement, patients receiving methadone were more likely to be may improve outcomes. Studies have shown a retained in MAT at 4- and 6-month follow-ups than range of patterns of use of MAT over time, and that those receiving buprenorphine/naloxone. Heroin- patient functioning should determine the duration assisted treatment in the United Kingdom was of treatment (Alcohol and Drug Abuse Institute, associated with better retention than methadone 2015). among patients who were treatment refractory. Authors found that contingency management (CM) The APA guideline notes that while “psychotherapy was the only behavioral therapy showing promise can enhance the effectiveness of pharmacotherapy,” to increase retention in MAT for opiate dependence. it also emphasizes, “pharmacotherapy enhances They noted that although CM has relatively strong the efficacy of psychotherapy since these two empirical support in the treatment of addictions, treatments have different mechanism of action and clinical practices do not always adopt its use due targeted effects that can counteract the weaknesses to barriers, e.g., clinicians’ beliefs that it does of either treatment alone” (APA, p.38). In concert not address the underlying causes of addiction. with the APA guideline, The SAMHSA Treatment Authors suggested more randomized controlled Improvement Protocol (TIP) 49—Incorporating trials addressing longer-term association between Alcohol Pharmacotherapies into Medical Practice

©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 15 medications and behavioral therapies (greater than do not provide relapse prevention medications. one year) and outcomes of MAT such as retention. Authors concluded that the results of this study provide additional support for the effectiveness of A recent naturalistic study, using retrospective integrating relapse prevention medication for opioid chart reviews (from admission through 24 weeks) addiction in this young population. They further of 56 admissions, examined the early experience noted the success of delivery in a community of a specialty community treatment program for treatment setting and in a model emphasizing young adults (mean age – 23.1 years) with opioid medication initiation at the inpatient level of care addiction, the Young Adult Alternative Program (Vo et al., 2016). (YAPP) (Vo et al., 2016). The treatment program featured the use of relapse prevention medications, A longitudinal time series analysis of data, using i.e., buprenorphine or extended release-naltrexone linear regression, included the number of 1995- (XR-NTX) with psychosocial treatment; treatment 2009 heroin overdose deaths from the Baltimore outcomes included retention and weekly opioid- City Health Department as well as the number negative urine tests. More than 80 percent of the of patients receiving treatment with methadone, patients entered the YAAP following detoxification buprenorphine/naloxone, or buprenorphine for at an affiliated program on the same campus where opioid dependence during the same period. The they began either buprenorphine or XR-NTX prior study examined the relationship between heroin to discharge. Patients’ beginning level of care was overdose deaths and the number of patients treated the intensive outpatient services (IOP—ASAM Level with methadone and buprenorphine (Schwartz et 2.1), which included three to five clinical sessions al., 2013). After FDA approval of buprenorphine per week with gradual taper of both intensity and for the treatment of opioid dependence in 2002, contact hours (depending on patient functioning). the medication became available through formerly More than 75 percent of patients received treatment drug-free outpatient clinics, private physician with buprenorphine and almost 25 percent of offices and in some community health centers in patients received XR-NTX treatment. Patients also Baltimore. From 1995 through 2009, the number received both group and individual counseling, of patients treated with opioid agonist treatment, physician visits for medication management, mental i.e., methadone and buprenorphine, quadrupled health therapy, and psychiatric treatment for co- while heroin overdose deaths declined. Authors occurring disorders. acknowledged a “clear inverse relationship between heroin overdose deaths and expansion of Results of this review found retention 65 percent buprenorphine treatment” and suggested that the at 12 weeks and 40 percent at 24 weeks. Rates of expansion of evidence-based medication treatment opioid negative urine tests were 50 percent and 39 of opiate dependence has the potential to reduce percent at 12 weeks and 24 weeks, respectively. heroin overdose deaths. Results found no differences between medication groups in rates of retention or rates of weekly While the use of MAT in medical or psychiatric opioid negative urine tests. Males had higher practice settings represents a small percentage rates of retention across the 24 weeks and higher of those who both seek and need treatment for rates of opioid negative urine tests (possibly SUDs, the trend is increasing. Numerous barriers to due to differences in baseline severity). Authors utilization of these medications include reluctance emphasized that this review “illustrates that on the part of patients to take medications along integration of relapse prevention medications as with their side effects and cost. Both substance standard of care is feasible and well-accepted abuse and MAT maintain a negative social stigma among young adults in a community treatment due to the belief that “one is simply transferring setting” (VO, p. 9). They also highlighted the addiction from one drug to another” (Magellan, treatment pathway of induction at the inpatient 2016). Utilization of MAT is affected negatively level of care followed by continuation at the IOP by the limited number of providers available with and and outpatient services (OP) level of care, while training and experience with MAT. Similarly, noting that most inpatient detoxification episodes treatment providers need to be educated on

16 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc evidence-based MAT protocols in order to address pre-conceived notions of their ineffectiveness and reduction in patient motivation to comply with behavioral treatments and counseling programs. In addition, clinicians need to find value in devoting more time to patient management while employing MAT protocols in this patient population as this worthy investment is likely to reduce the possibility of relapse and/or readmission to a substance abuse inpatient/residential rehabilitation program.

Over the last three decades, the substance abuse no treatment in time to failure (Krebs et al., 2009). services system has shifted from primarily In turning to the adolescent population, a meta- residential to non-residential settings. This has analysis conducted in 2010 of substance abusing prompted the need to understand if substance abuse teenagers (n=30 residential programs; 27 outpatient treatment processes and outcomes vary across programs) also demonstrated statistically service setting. A formal predictive ability analysis significant improvements in their problems for of the ASAM-PPC was conducted in 2003, where treatment in both levels of care. For outpatient investigators rated patients (n=248) using both an programs, days abstinent (out of 90) increased ASAM criteria algorithm and a clinical evaluation from 52 to 64 days on average and for residential algorithm. As hypothesized, patients receiving programs, days abstinent (out of 90) increased from undertreatment (i.e., regular outpatient care when 21 at intake to 45 at follow-up (Tanner-Smith et intensive outpatient was needed) predicted poorer al., 2010). All of these findings contribute scientific drinking outcomes compared with appropriately data on the differential effectiveness of community- matched treatment. In addition, overtreatment (i.e., based residential and outpatient substance abuse outpatient treatment recommended but treated in treatment and underscore the need to continue inpatient rehabilitation) did not improve outcomes. empirical research examining the continuum of Thus, researchers concluded that matching to care construct and relevant outcomes. the level of care is optimal, undertreatment is clinically harmful, and overtreatment is wasteful The ASAM Criteria notes how withdrawal of resources. Moreover, it was found that aftercare management has historically been considered an treatment and participation in 12-step group inpatient procedure, but with current medication programs along with patient attributes (i.e., protocols all but the most severe withdrawal motivation for change) and psychiatric symptom syndromes can be managed effectively on an severity influence treatment outcome (Magura et al., ambulatory basis. It also emphasizes that the 2003; Magura et al., 2005). continuation of withdrawal support at less intensive levels of withdrawal management is critical because Other more recent studies have been conducted persisting post-acute withdrawal discomforts can directly comparing the treatment effectiveness lead patients to a return to substance use (ASAM, of residential versus outpatient substance abuse 2015). treatment. One large study conducted in 2007 using male and female prison parolees (n=4,165) who completed prison-based substance abuse treatment found that these subjects benefited equally from outpatient and residential aftercare, regardless of the severity of their drug/alcohol problem (Burdon et al., 2007). Another very large survival analysis (n=129,577) of drug-involved offenders on probation followed subjects for up to six years showing outcomes for outpatient substance abuse treatment were actually superior to residential services. Investigators reported that when comparing “time to fail” or recidivate, those receiving nonresidential treatment took longer—specifically, increasing the mean expected time until arrest for a felony by 22 percent. Conversely, those receiving residential treatment did not differ from those who received

Assessment and treatment of substance use disorders are possible without major disruption to an individual’s life. Well-researched psychosocial treatments along with highly effective medications are accessible within the community. Treatment professionals, legislators, third-party payers and patient advocates bear the responsibility to promote best clinical practices, support prevention services and eliminate potential barriers to treatment and recovery. Magellan’s MAT program is based on professional standards, including those developed by the American Psychiatric Association’s Physician Consortiuim for Performance Improvement® and in consideration of the American Society of Addiction Medicine’s National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (2015). Magellan endorses current research showing that the best treatment is at the least intensive level of care that manages the patient safely and comfortably and where the patient can be engaged in continued treatment that will lead to a sustained recovery from addiction. Magellan has been using MAT since 2011 in this way. Practitioners were educated regarding the benefits of MAT, and patients, at the time of discharge from inpatient withdrawal services, were begun on MAT. Through this educational effort, we were able to report a significant increase in the use of MAT medications over a one-year period. We believe that the use of MAT in combination with psychosocial therapies, can reduce cravings for both alcohol and opiates, and can reduce the need for admissions and readmissions. MAT can promote return to the community, employment and full contribution to society.

1. Alcohol & Drug Abuse Institute (University of 10. Center for Substance Abuse Treatment. Washington) 2015. Medication Assisted Treatment Incorporating Alcohol Pharmacotherapies Into for Opioid Use Disorders: Overview of the Medical Practice (TIP) Series 49. DHHS Publication Evidence. Accessed online at http://adai.uw.edu/ No. (SMA) 09-4380. Rockville, MD: Substance Abuse pubs/infobriefs/MAT.pdf. and Mental Health Services, 2006.

2. American Psychiatric Association 2006. Practice 11. Center for Substance Abuse Treatment, What Guideline for the Treatment of Patients with are Peer Recovery Support Services? HHS Substance Use Disorders, 2nd Edition. Published Publication No. (SMA) 09-4454. Rockville, MD: August 2006. Am J Psychiatry 2006; 163(8): 1-82. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and 3. American Psychiatric Association 2007. Human Services, 2009. Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients With Substance Use 12. FDA. FDA announces enhanced warnings for Disorders, 2nd Edition. immediate-release opioid pain medications related to risks of misuse, abuse, addiction, overdose 4. American Psychiatric Association. Diagnostic and death. Accessed online on March 23, 2016 and Statistical Manual of Mental Disorders: Fifth at http://www.fda.gov/NewsEvents/Newsroom/ Edition DSM-5™. American Psychiatric Publishing, PressAnnouncements/ucm491739.htm. Washington, DC; London, England, 2013. 13. Fishman MJ, Shulman GD, Mee-Lee D, 5. American Society of Addiction Medicine. The Kolodner G, Wilford BB, eds. (2010). ASAM ASAM National Practice Guideline for the Use Patient Placement Criteria: Supplement on of Medications in the Treatment of Addiction Pharmacotherapies for Alcohol Use Disorders. Involving Opioid Use. 2015. Chevy Chase, MD: American Society of Addiction 6. Bachhuber MA, Hemessy S, Cunningham Medicine, Inc. CO, Starrels JL. Increasing benzodiazepine 14. Granfield, R, & Cloud, W (1999).Coming Clean: prescriptions and overdose mortality in the Overcoming addiction without treatment. New United States, 1996 – 2013. York: New York University Press.

7. Burdon WM, Dang J, Prendergast ML, Messina 15. Krebs CP, Strom KJ, Doetse WH, Lattimore PK. NP, Farabee D. Differential effectiveness of The Impact of Residential and Nonresidential residential versus outpatient aftercare for parolees Drug Treatment on Recidivism Among Drug- from prison-based therapeutic community Involved Probationers. Crime and Delinquency, treatment programs. Substance Abuse Treatment, Volume 55, Number 3, July 2009. Prevention, and Policy 2007. 2:16. 16. Magellan Health Services. Ultra Rapid (or 8. Carroll KM, Ball SA, Martino S. (2007). Rapid) Opiate Detoxification Under General Cognitive, Behavioral and Motivational Therapies Anesthesia, Technology Assessment Report, March for Substance Abuse Disorders. In Gabbard’s 2007. Treatment of Psychiatric Disorders, 4th Edition. American Psychiatric Press, Inc. 17. Magellan Health Services. VIVITROLTM (naltrexone for extended-release injectable 9. Center for Disease Control and Prevention (CDC). suspension) for the treatment of Opioid Addiction Increases in Drug and Opioid Overdose Deaths— and Alcohol Dependence, Technology Assessment United States, 2000 – 2014. Accessed online at Report, May 5, 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6450a3.htm.

20 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc 18. Magellan Healthcare. Introduction to Clinical 27. Neumann AM, Blondell RD, Azadfard M, Practice Guidelines for the Assessment and Nathan G, Homish GG. Primary care patient Treatment of Patients With Substance Use characteristics associated with completion of Disorders, March 2015. 6-month buprenorphine treatment. Addict Behav 2013; 38(11): 2724-8. 19. Magellan Healthcare. Medication Assisted Treatment: Taking Aim at America’s Hidden 28. Priester MA, Browne T, Iachini A, Clone S, Epidemic, 2016. DeHart D, Seay KD. Treatment access barriers and disparities among individuals with co-occurring 20. Magellan Healthcare. Magellan Ambulatory mental health and substance use disorders: an Detoxification Monograph, 2015. integrative literature review. Journal of Substance 21. Magura S, Fong C, Staines GL, Cleland C, Abuse Treatment 2016; 61:47-59. Foote J, Rosenblum A, Kosanke N, DeLuca A. 29. Principles of Drug Addiction Treatment: A The combined Effects of Treatment Intensity, Research Based Guide. Available http://www. Self-Groups and Patient Attributes on Drinking drugabuse.gov/PODAT/Evidence.html February 23, Outcomes. Journal of Psychoactive Drugs, Volume 2010. 37 (1), March 2005. 30. SAMHSA. Center for Behavioral Health 22. Magura S, Staines G, Kosanke N, Rosenblum Statistics and Quality 2015. Behavioral health trends A, Foote J, DeLuca A, Bali P. Predictive in the United States: Results from the 2014 National Validity of ASAM Patient Placement Criteria Survey on Drug Use and Health (HHS Publication for Naturalistically Matched vs. Mismatched No. SMA 15-4927, NSDUH Series H-50). Retrieved Alcoholism Patients. The American Journal on from http://www.samhsa.gov/data/sites/default/files/ Additions, 12: 386-397, 2003. NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.

23. Mauger S, Fraser R, Gill K. Utilizing 31. SAMHSA. Center for Substance Abuse buprenorphine-naloxone to treat illicit and Treatment. Detoxification and Substance Abuse prescription opioid dependence. Neuropsychiatr Treatment. Treatment Improvement Protocol Dis Treat 2014; 10:587-598. (TIP) Series 45. DHHS Publication No. (SMA) 0613- 24. Mee-Lee D, Shulman GD, Fishman M, Gastfriend 4131. Rockville, MD: Substance Abuse and Mental DR, and Griffith JH,Miller MM, eds. (2013).The Health Services, 2006. ASAM Patient Placement Criteria: Treatment 32. SAMHSA. Center for Substance Abuse Criteria for Addictive, Substance-Related, and Treatment. Substance Abuse Treatment for Co-Occurring Conditions of Substance-Related Persons With Co-Occurring Disorders. Treatment Disorders, Third Edition. American Society of Improvement Protocol (TIP) Series 42. DHHS Addiction Medicine. Carson City, NV: The Change Publication No. (SMA) 06-413113-3992. Rockville, ® Companies . MD: Substance Abuse and Mental Health Services, 25. National Council on Alcohol and Drug 2005. Dependence (NCADD). More than 47,000 Americans 33. SAMHSA’s National Registry of Evidence-based Died from Drug Overdoses in 2014. Accessed online Programs and Practices. Available at http://nrepp. at https://www.ncadd.org/blogs/in-the-news/more- samhsa.gov February 23, 2010. than-47-000-americans-died-from-drug-overdoses- in-2014. 34. Schwartz RP, Grycynski J, O’Grady KE, Sharfstein JM, Warren G, Olsen Y, Mitchell SG, 26. National Institute on Drug Abuse (NIDA). Abuse Jaffe JH. Opioid agonist treatments and heroin of Prescription (Rx) Drugs Affects Young Adults overdose deaths in Baltimore, Maryland, 1995-2009. Most. Accessed online at https://www.drugabuse. American Journal of Public Health 2013; 103(5): gov/drugs-abuse. 917-922.

©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 21 35. Sells, D, Davidson, L, Jewell, C, Falzer, P, & 42. Weaver MF, Hopper JA, Gunderson EW. Designer Rowe, M (2006). The treatment relationship in drugs 2015: assessment and management. Addiction peer-based and regular case management for Science & Clinical Practice 2015; accessed online clients with severe mental illness. Psychiatric at http://download.springer.com/static/pdf/875/ar Services, 57, 1179-1184. t%253A10.1186%252Fs13722-015-0024-7.pdf?origin Url=http%3A%2F%2Fascpjournal.biomedcentral. 36. Shin HC, Marsh JC, Cao D, Andrews CM. Client- com%2Farticle%2F10.1186%2Fs13722-015-0024-7&to Provider relationship in comprehensive substance ken2=exp=1457884989~acl=%2Fstatic%2Fpdf%2F87 abuse treatment: Differences in residential and 5%2Fart%25253A10.1186%25252Fs13722-015-0024-7. nonresidential settings. Journal of Substance pdf*~hmac=0a2feaec0bea4b8f0a33b98ec0535b8b7e Abuse Treatment 41 (2011) 335—346. 680ab4cbbe70612af132c0c49f9f28. 37. Substance Abuse and Mental Health Services Administration Leading Change: A Plan for SAMHSA’s Roles and Actions 2011 – 2014, HHS Publication No. (SMA) 11-4629, Rockville, MD. Substance Abuse and Mental Health Services Administration, 2011.

38. Tanner-Smith EE, Lipsy MW, Wilson SJ. Comparative Effectiveness of Substance Abuse Treatment Programs for Adolescents: Results from Three Meta-analyses. [Power Point slides] Presented at the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore, MD, December 14-16, 2010.

39. Thomas CP, Fullerton CA, Kim M, Montejano L, Lyman DR. Medication-assisted treatment with buprenorphine; assessing the evidence. Psychiatr Serv 2014; 65(2): 158-70.

40. Timko C, Schultz NR, Cucciare MA, Vittorio BA, Garrison-Diehn CG. Retention in medication- assisted treatment for opiate dependence: a systematic review. Journal of Addictive Diseases 2016; 35(1): 22-35.

41. Vo HT, Robbins E, Westwood M, Lezama D, Fishman M. Relapse prevention medications in community treatment for young adults with opioid addiction. Subst Abus 2016.

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